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Thrombocytopenic Purpura (ITP) Feedback Menu
In evaluating case performance, the domains of diagnosis (including physical exam and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.
In this case, a 5-year-old boy is brought to the emergency department by his mother because of recurrent nosebleeds. Initially the differential diagnosis is narrow; however, the comprehensive history broadens the differential. The patient has had recurrent nosebleeds during the past 24 hours. The bleeding stops after applying direct pressure. He also has a red rash and a recent history of upper respiratory tract infection. The onset of bleeding and a rash, along with the recent history of upper respiratory tract infection, suggests the possibility of a coagulation disorder.
Physical examination shows blood oozing slowly from the right naris and a petechial rash on the face, arms and legs. The patient is frightened and crying. There is no lymphadenopathy or splenomegaly. The remainder of the physical examination is unremarkable. The patient's illness, at this point, would still seem most consistent with a hematologic process. Most cases of nosebleed last a short time, are self-limited, and require no diagnostic work-up or intervention. In this case, however, the co-occurrence of bleeding and rash, the recurrent nature of the nosebleeds, and the antecedent viral illness necessitate further diagnostic evaluation and appropriate treatment.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.
An optimal, efficient, and effective approach would include performing an appropriate physical (including lymph node, HEENT/neck, chest/lung, cardiovascular, abdominal, and skin or extremities examinations), controlling the oozing blood by ordering direct pressure to the nose, and ordering a complete blood count (CBC). Once the low platelet count is discovered and the peripheral smear inspected, a reticulocyte count should be ordered to help rule out hemolysis and elucidate the cause of the thrombocytopenia, which in this case is acute ITP.
Since there is no consensus about the management of acute ITP in children and serious bleeding is rare, inpatient observation and monitoring the platelet count would be acceptable management. Alternatively, administration of intravenous immunoglobulin (IVIG) is equally acceptable. Other acceptable treatment alternatives include administration of corticosteroids (provided a bone marrow examination is done first to exclude leukemia) or administration of IV Rho(D) immune globulin (after verifying that the patient is Rh positive). Regardless of the ITP treatment option, the patient’s platelet count should be monitored through repeat CBCs.
Note that the benefit of measuring platelet antibodies remains debatable as does performing bone marrow aspirate/biopsy except as a precursor to steroid treatment.
Examples of additional tests and treatments that might be ordered but would be neither useful nor harmful to the patient management include:
Antibody, antinuclear
Antibody, antiphospholipid
Antibody, hepatitis C
Polymerase chain reaction, HIV, DNA
Examples of suboptimal management of this case would include delay in ordering the CBC or failure to treat the nosebleed. Examples of poor management would include failure to identify the thrombocytopenia by ordering a CBC or failure to monitor the platelet count.
Examples of treatments that would subject the patient to unnecessary discomfort or risk and add no real benefit to this patient include:
Antiplatelet therapy
Intramuscular medications
ICU admission
Nasal cauterization
Transfusion with whole blood or packed red blood cells
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